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Received 12 May 2021 | Revised 20 June 2021 | Accepted 30 July 2021 | Published Online 9 Aug 2021

 CMI JOURNAL 2 (3), 155−162  (2021)
ISSN (O) 2694-4626 

RESEARCH ARTICLE

Diagnostic Yield of Endoscopic Ultrasonography–Guided Fine-Needle 
Aspiration (Eus-Fna) for Solid Pancreatic Masses

Sara Ghani∗  
| Mouna Salihoun*  | Hadj Omar El Malki 1,2  | Mohamed Acharki * | Nawal 

Kabbaj *

*EFD-Hepatogastroenterology unit,
Ibn Sina Hospital, Mohammed V
University of Rabat-Morocco.

1,2Biostatical, clinical research and
epidemiological laboratory
(LBRCE), Medical School,
University Mohammed V. Souissi,
Rabat, Morocco

Abstract
Background:
Endoscopic ultrasound-Fine-needle aspiration (EUS)-FNA is one of the 
most sensitive and accurate modalities, for detecting and staging 
pancreatic masses and for obtaining a histological diagnosis. Our stud-ies 
aim to assess the diagnostic yield of EUS-FNA in solid pancreatic masses.
METHODS: Forty-five patients with solid pancreatic masses on im-agery 
were included out of 230 EUS performed between September 2018 and 
January 2020. All the patients, underwent EUS-FNA using 19G or 22G 
needles. All the masses were divided into 2 groups based on mass size: group 
A (< 30 mm) and group B (> 30mm). Sensitivity, nega-tive predictive value 
(NPV), and diagnostic accuracy were respectively evaluated. The specificity 
and positive predictive value were 100% in both groups. Statistical analysis 
was performed using SPSS, and the significance level was set at p <0.05.
RESULTS: Overall, sensitivity and diagnostic accuracy were signif-
icantly higher in group B (80,7% vs 46% (p=0,01), and 89,2% vs 
58,8%(p=0,02)). Only the sensitivity was significantly higher with 19 G 
(p=0,02) in group A. In group B, the sensitivity and diagnostic accuracy were 
higher with 22G (71% vs 50% (p=0,6), 93,3% vs 69,5% (p=0,5), despite 
more passes were performed with 22G (2,55 ± 0,59 vs 1,96 ± 0,56 p = 
0.001). The multivariate analysis showed that the risk of getting a negative 
EUS-FNA is 6,46 times higher in group A (p=0,009). CONCLUSION: The 
diagnostic yield of EUS-FNA is correlated at the pancreatic mass size and 
the risk to get a negative EUS-FNA is 6,46 times higher for masses 
<30mm.
Keywords: EUS-FNA, Solid mass, Needle size, Puncture route, Lesion size.

Copyright : © 2021 The Authors. Published by Medical Editor and
Educational Research Publishers Ltd. This is an open access article

under the CC BY-NC-ND license

(https://creativecommons.org/licenses/by-nc-nd/4.0/)

CMI JOURNAL 2 (3), 155−162 MEERP LTD 155

https://creativecommons.org/licenses/by-nc-nd/4.0/


1 BACKGROUND:

Pancreatic cancer is the seventh leading cause
of death from cancer in the world. The diag-
nosis is often difficult at an early stage and

subsequently delayed (1). The arrival of Endoscopic
Ultrasound-Fine-Needle Aspiration (EUS)-FNA, al-
lowed the diagnosis and staging of pancreatic mass
lesions. It is one of the most sensitive and accurate
modalities for detecting and evaluating pancreatic
mass and for obtaining a histological diagnosis (2).
However, many factors can affect the diagnostic
yield of EUS-FNA. Our studies aim to evaluate the
factors affecting the diagnostic yield of EUS-FNA in
solid pancreatic masses.

2 METHODS:

Study population:
We retrospectively included all the patients with a
solid pancreatic mass, who underwent EUS-FNA
using the 19G or the 22G needle, between September
2018 and January 2020 at Endoscopy and gastroen-
terology Unit of IBN SINA University Hospital. In
total, 230 EUS with 112 FNAs were performed by
two endosonographers during this period. Patients
with cystic lesions were excluded from the present
study (Figure1). Among all patients, four underwent
surgery; 3 cases of neuroendocrine tumor (NET) and
2 cases of solid pseudopapillary neoplasm (SPN) and
the final diagnosis was similar to the FNA histology
(Figure 1).

FIGURE 1: 1: Flow chart of the current study

Study design:

The study was divided into two groups based on
the mean size of the pancreatic mass, obtained by
endoscopic ultrasonography measurements: group A
(< 30 mm) and group B (> 30 mm). Overall, fifteen
patients had first negative EUS-FNA, subsequently,
a second EUS-FNA was performed in 5 patients and
only the final diagnosis was considered.
The main indication of the EUS-FNA was to ob-
tain histological subtype for unresectable pancreatic
cancer in 29 cases (64,5%) and suspected pancreatic
cancer in 16 cases (35,5%).
EUS-FNA procedure:
The radial echoendoscope was introduced in our
unit in 2015, and the linear echoendoscope became
available in August 2018.
All EUS procedures were performed under deep se-
dation with propofol. A linear echoendoscope (PEN-
TAXHITACHI) was used by two endosonographers
according to ESGE recommendations (3). Once the
pancreatic mass has been identified, the operators
measure the size in section, assess the local exten-
sion, then choose the puncture route according to the
mass location, the distance between the mass and the
probe and their preferences. The mass was punctured
via the transgastric or the transduodenal route using
19G or 22G (Medi-globe ®). In the beginning, only
19Gwas available in our endoscopy unit until March
2019, 22G became available. Several needle passes
were performed with fanning and the samples were
directly placed in Cytolyt® according to the standard
ESGE protocol (3), then sent to an advanced pathol-
ogist for analysis. All specimens were classified as
malignant, benign or negative (nondiagnostic). All
patients were kept under observation after the proce-
dure (Figure 2).

Supplementary information The online version of
this article (https://doi.org/xx.xxx/xxx.xx) contains
supplementary material, which is available to autho-
rized users.

Corresponding Author: Sara Ghani
EFD-Hepatogastroenterology unit, Ibn Sina Hospital,
Mohammed V University of Rabat-Morocco.
Email: saraghanimed@gmail.com

CMI JOURNAL 2 (3), 155−162 MEERP LTD 156

mailto:saraghanimed@gmail.com


DIAGNOSTIC YIELD OF ENDOSCOPIC ULTRASONOGRAPHY–GUIDED FINE-NEEDLE
ASPIRATION (EUS-FNA) FOR SOLID PANCREATIC MASSES

FIGURE 2: Inser on of the needleinto the 
pancrea c mass

In this study, the final diagnosis of malignancy and
benignity was established based on clinical signs,
biology, image features, and histopathology of the
surgical specimen and the EUS-FNA.
(1) Absence of clinical, biological, imagery and
EUS-FNA criteria of malignancy (with 6 months
minimum of follow-up).
(2) Presence of criteria of malignancy and positive
surgical specimens.
(3) Presence of clinical, biological, imaging and
EUS-FNA criteria of malignancy.
(4) Presence of clinical signs, biology and imaging
criteria of malignancy with negative EUS-FNA.
Outcomes measurements:
The primary outcomewas themeasures of the overall
diagnostic yield of EUS-FNA in the pancreatic solid
masses, then in each group and with each needle.
The sensitivity was defined by the percentage of
malignancies diagnosed by EUS-FNA.
The diagnostic accuracy was defined by the percent-
age of positive histology obtained by EUS-FNA. The
absence of clinical, biological, imaging and EUS-
FNA criteria of malignancy was considered a true
negative. The presence of clinical, biological and
imaging criteria of malignancy with negative EUS-
FNA, was considered to be a false negative. There
were no false positives. The histology of the surgical
specimens was similar to the first histology obtained
by EUS-FNA.

The secondary outcomes were the measures of the
difference between; the size of the mass and needle
used; mass location; puncture site; the number of
needle passes; fanning, and positive FNA (Table 1).

TABLE 1:  Diagnos c yield in each group

Data and statistical analysis:

Statistical analysis was done using SPSS® software
(IBM, Armonk, New York, USA). The means +/-
standard deviation (SD) and frequency, percentage
were used respectively for quantitative variables
with normal distribution and qualitative variables.
The difference between the size of the mass, the
number of needles passes in positive EUS-FNA was
done using Student’s t-test. Significance was set at p
<0.05.
The univariate analysis was done with Fisher’s exact
test. Sensitivity, specificity, positive and negative
predictive value and diagnostic accuracy were cal-
culated based on the final diagnosis and compared
using Fisher’s exact test. Significance was set at p
<0.05. The results of the multivariate analysis were
studied using binary regression analysis, and only
factors with
p < 0,2 in the univariate analysis were introduced.
The significance level was set for p < 0.05. Data are
presented with odds ratios (OR) and their respective
95% confidence intervals (CI).

3 RESULTS:

Fifty EUS-FNA (21,7%) were performed on 45 pa-
tients over this period out of 230 EUS. The mean age
was 56,42 ± 14,1 years, and the mean size of the
mass was 39,46 ± 16, 82mm. There were 17 masses
(37,8%) in group A and 28 masses (62,2%) in group
B. The 19G needle was used in 23 cases (51,1%)

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The final diagnosis (4, 5):



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GHANI ET AL.

and the 22G in 22 cases (48,9%) with 2,24 ± 0,64
passes per lesion, without any major complication.
The histology showed malignancy disease in 62,1%
(Table 2).
Table 2: Demographic characteristics of the pa-
tient in each group (Fisher’s exact test)

* (2 SPN+ pancreatic Metastasis)
Primary outcomes:
Overall, sensitivity, specificity, positive predictive
value, negative predictive value, and diagnostic ac-
curacy were respectively :73,6%,100%, 100%, 41%,
and 77,7%.
Sensitivity, negative predictive value (NPV), and
diagnostic accuracy in groups A and B were re-
spectively: 46,15% vs 88% (p=0,03), 36,3% vs 50%
(p=0,9), 58,5% vs 89% (p=0,02). There is a sig-
nificant difference in the sensitivity and diagnostic
accuracy of each group, they increased significantly

as the mass size increased (p=0,03 et 0,02). The
negative predictive value was not significant in the
groups (p=0,9).
However, the specificity and the positive predictive
value (PPV) are 100% in both groups (Table 3).

TABLE 3: Diagnos c yield in each group

Fisher’s exact test
The sensitivity and diagnostic accuracy with needles
19G and 22G in group A were respectively: 50% vs
33,3% (p=0,02) and 50% vs 71% (p=0,6). There is a
statistically significant difference in sensitivity with
needles 19G and 22G in group A.
The sensitivity and diagnostic accuracy of needles
19G and 22G in groupBwere: 80%vs 93,3% (p=0,6)
and 69,5% vs 93,3% (p=0,5), this difference was not
statistically significant (Table 4).

MEERP LTD CMI JOURNAL 2 (3), 155−162  (2021) 158

TABLE  4: Diagnos c yield of 19G and 22G needles 
in each group

Secondary outcomes:



DIAGNOSTIC YIELD OF ENDOSCOPIC ULTRASONOGRAPHY–GUIDED FINE-NEEDLE
ASPIRATION (EUS-FNA) FOR SOLID PANCREATIC MASSES

TABLE 4: 7: Mul variate analysis of factors could 
affect the percentage of nega ve EUS-FNA.

4 DISCUSSION:

Overall, sensitivity, specificity, positive predictive
value, negative predictive value, and diagnostic ac-
curacy were respectively :73,6%,100%, 100%, 41%,
and 77,7%.
Crino et al. showed in their study that the sensitivity,
specificity, positive predictive value, negative pre-
dictive value, and diagnostic accuracy were respec-
tively: 85.2%, 81.8%, 93.7%, and 80.4% (6).
Several studies have been interested in factors affect-
ing the diagnostic yield of EUS-FNA
(2–7), and the first outcome is mass size.We showed
through this study that the diagnostic yield is sta-
tistically correlated to the mass size, in particular
for masses > 30mm in size. Sensitivity and diagnos-
tic accuracy were respectively: 88% and 89%. By
multivariate analysis, we showed that only size is
considered as a potential factor to affect EUS-FNA.
Many studies have shown that the sensitivity and
diagnostic accuracy increase significantly as
the size of the pancreatic mass increases. Sugiura
et al. demonstrate that sensitivity and diagnostic
accuracy are significantly higher for lesions >10mm
in size, and increase as the lesion size increases.

CMI JOURNAL 2 (3), 155−162  (2021) MEERP LTD 159

We performed a univariate analysis of all 
variables that could affect the outcome of the 
EUS-FNA. A significant difference was found in 
mass sizes and the positive FNA (p=0,02) 
calculated using Stu-dent’s t-test. No significant 
difference between pos-itive FNA and diameter 
of the needle used (p=0,5), mass location 
(p=0,2), puncture route (p=0,5), and number of 
passes (p=0,3) was found (Table 5).

Table 5 : Univariate analysis of all variables

Fisher’s exact test

Therefore, there was a significant difference in the
number of passes with the 22G needle (p=0,001)
(Table 6).

Table 6: Number of passes of each needle

In multivariate analysis, independent variables in-
cluded the mass size (groups A and B), the negative
EUS-FNA, the location of the mass.
We found that the risk of obtaining a nega-
tive EUS-FNA is 6,46 times higher in group A 
(mass < 30mm) (confidence interval (CI) :1,6-26,13, 
p=0,009). Moreover, the mass location was not a sig-
nificant factor in affecting the percentage of negative 
EUS-FNA (Table 7).

Student’s t-test



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GHANI ET AL.

In their study, they divided the patients into five
groups according to the lesion size (A<1cm; B: 1-
2cm; C: 2-3cm; D: 3-4cm and E>4cm), and they
found that the sensitivity and the diagnostic accuracy
were respectively: 89.9% vs 95% vs 97.4%; 98.5%
vs 98.7% (p < 0,01) and 91.7% vs 96.4% vs 97.7%
98.6% vs 98.7% (p = 0,03) (7).
A multi-centric study including 164 patients with
solid pancreatic masses, has shown that the sensitiv-
ity and diagnostic accuracy were 83% and 85% for
lesions between 28,5mm and 41,3mm in size (8).
The second outcomes are the size of the needle,
number of passes and fanning. Three sizes of EUS-
FNA needles are commercialized: 19G, 22G, and
25G (9). The choice of the needle depends; on the
mass size, the puncture route and the preference of
endosonographers (10). The needle 22G is the most
commonly used (11). In our study, only the sensitiv-
ity was significantly higher with the needle19G for
masses with a size < 30mm (p=0,02). There was no
significant difference in diagnostic accuracy (p=0,6)
between needles in group A. For masses > 30mm in
size, sensitivity and diagnostic accuracy were higher
with the needle 22G (71% vs 50% (p=0,6), 93,3% vs
69,5% (p=0,5). This difference is not significant.
A prospective randomized trial conducted by Itoi et
al. showed that the sensitivity of the needle 19G was
significantly higher than 22G for the diagnosis of
malignancies (12). An algorithm has been proposed
by Bang et al regarding the choice of the needle (13).
By univariate analysis, we showed that there was
no significant difference between the diameter of
needles 19G and 22G and FNA positive: 93,3% vs
69,5% (p=0,5). A randomized trial conducted by
Ramesh and al. has shown the same result regarding
the performance of 19G and 22G (14).
There was no significant difference between the
number of needle passes and FNA positive (p=0,8)
in our studies. ESGE recommends 5 passes for solid
pancreatic masses (15). LeBlanc et al. have shown
that sensitivity increases as the number of passes
increase with the needle 22G (16).
A randomized trial showed that there was no sig-
nificant difference in diagnostic accuracy between
the fanning and the standard technique (p=0,05).

However, a few passes were required with fanning
to establish the diagnosis of malignancy (17).

5 CONCLUSION:

We showed in the current study, that the risk to
get a negative EUS-FNA is 6,46 times higher for
masses <30mm and the sensitivity of 19G needle for
malignancy was higher than 22G needle for these
masses.
LIST OF ABBREVIATIONS:
EUS-FNA: Endoscopic Ultrasound-Fine-needle as-
piration
19G needle: 19 Gauge needle
22G needle: 22 Gauge needle
NET: Neuroendocrine tumor
SPN: Solid pseudopapillary neoplasm
SD: Standard deviation
CI: Confidence intervals
OR: Odds ratios
PPV: Positive predictive value
NPV: Negative predictive value
DECLARATIONS:
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Availability of data and materials:
The datasets used and/or analysed during the current
study are available from the corresponding author on
reasonable request.
Acknowledgements:
Not applicable.
The authors declare that they have no competing
interests.
Funding: Not applicable
Authors ‘contributions: All authors declare that they
have all participated in the design, execution, and
analysis of the paper, and that they have approved
the final version.

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DIAGNOSTIC YIELD OF ENDOSCOPIC ULTRASONOGRAPHY–GUIDED FINE-NEEDLE
ASPIRATION (EUS-FNA) FOR SOLID PANCREATIC MASSES
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How to cite this article: Ghani S., Salihoun M., 
H.O.E.M., M.A., N.K. DIAGNOSTIC YIELD 
OF ENDOSCOPIC ULTRASONOGRAPHY–
GUIDED FINE-NEEDLE ASPIRATION 
(EUS-FNA) FOR SOLID PANCREATIC 
MASSES. Clinical Medicine Insights. 2021;155
−162 . https://doi.org/xx.xxx/xxx.xx

MEERP LTD CMI JOURNAL 2 (3), 155−162 (2021) 162


	Background:
	Methods:
	Results:
	DISCUSSION:
	CONCLUSION:



